Lars M. Ellison

PURPOSE: Upper tract urothelial cancer is rare but studies in the 1970s showed that its incidence was increasing. We evaluated national trends of the incidence and survival of upper tract urothelial neoplasms from 1973 to 1996. MATERIAL AND METHODS: We obtained information on upper tract urothelial neoplasms from 1973 to 1996 from the National Cancer Institute Surveillance, Epidemiology and End Results program. To provide a time comparison we evaluated upper tract urothelial cancer from 1973 to 1984 and 1985 to 1996. We also calculated overall disease specific survival stratified by cancer stage, patient race and gender for the study period overall. RESULTS: A total of 9,072 cases of upper tract urothelial cancer were identified in the Surveillance, Epidemiology and End Results program from 1973 to 1996, including 5,379 of the renal pelvis and 3,678 of the ureter. Comparing age adjusted annual incidence rates revealed an increase in ureteral neoplasms from 0.69 to 0.73/100,000 person-years but no change in the incidence of renal pelvic tumors, while the rate of in situ neoplasms increased from 7. 2% to 23.1%. Overall disease specific 5-year survival was significantly different in regard to tumor stage (95.1% in situ, 88. 9% localized, 62.6% regional and 16.5% distant lesions). Disease specific annual mortality was greater in black than in white individuals and in women than in men (7.4% versus 4.9% and 6.1% versus 4.4%, respectively). CONCLUSIONS: There appears to have been a slight increase in the national incidence of ureteral tumors in the last 23 years. Fortunately we also detected a slight improvement in the overall disease specific survival of patients with upper tract neoplasms.

PURPOSE: The incidence of renal cancer is increasing, while cases series suggest that tumor size is decreasing. This has important implications for treatment planning. We evaluated national trends in renal cancer size and observed survival in patients diagnosed in the 3 periods 1988 to 1992, 1993 to 1997 and 1998 to 2002. MATERIALS AND METHODS: From the Surveillance, Epidemiology, and End Results database we identified 29,053 patients diagnosed with primary renal cancer. Patients were stratified into size categories and 5-year time cohorts. Size distribution was compared across cohorts. Kaplan-Meier survival curves and Cox proportional hazards modeling were used to examine trends in overall and stage specific survival. RESULTS: From 1988 through 2002 renal tumor size decreased from 66.8 to 58.6 mm, while the age adjusted incidence of renal cancer increased from 8.6 to 11.2 cases per 100,000 individuals. Kaplan-Meier analysis showed steadily deteriorating survival with increased cancer size above 4 cm with a median survival of 105 months for 4 to 7 cm vs 46 months for more than 7 cm. Cox modeling demonstrated significantly improved survival in patients diagnosed in the latter cohorts. With adjustment for size the latter cohorts remained significantly improved compared to the earliest cohort, although the 1998 to 2002 cohort was no longer significantly different than the 1993 to 1997 cohort. CONCLUSIONS: Nationally renal tumor size at presentation has steadily and consistently decreased. Patients more recently diagnosed had improved survival, which could be attributable to decreased tumor size in the latter cohorts. Patients more recently diagnosed also demonstrated a relative survival advantage independent of size compared to the earliest patients studied.

PURPOSE: The value of radical prostatectomy for patients with prostate cancer depends on low morbidity and mortality. We assessed whether patient outcome is associated with how many of these procedures are performed at hospitals yearly. MATERIALS AND METHODS: Using the Nationwide Inpatient Sample, which is a stratified probability sample of American hospitals, we identified 66,693 men who underwent radical prostatectomy between 1989 and 1995. Cases were categorized into volume groups according to hospital annual rate of radical prostatectomies performed, including low-fewer than 25, medium-25 to 54 and high-greater than 54. We performed multivariate logistic regression to control for patient characteristics when assessing the associations of hospital volume, in-hospital mortality and resource use. RESULTS: Overall adjusted in-hospital mortality after radical prostatectomy was relatively low (0.25%). However, patients at low volume centers were 78% more likely to have in-hospital mortality than those at high volume centers (adjusted odds ratio 1.78, 95% confidence interval 1.7 to 2.6). Overall length of stay decreased at all hospitals between 1989 and 1995. However, average length of stay was longer and total hospital charges were higher at low than at high volume centers (7.3 versus 6.1 days, p<0.0001, and $15,600 versus $13,500, p<0.0001, respectively). CONCLUSIONS: Hospital volumes inversely related to in-hospital mortality, length of stay and total hospital charges after radical prostatectomy. Further study is necessary to examine the association of hospital volume with other important outcomes, including incontinence, impotence and long-term patient survival after radical prostatectomy.

BACKGROUND: It has been demonstrated that Agent Orange exposure increases the risk of developing several soft tissue malignancies. Federally funded studies, now nearly a decade old, indicated that there was only a weak association between exposure and the subsequent development of prostate cancer. Because Vietnam War veterans are now entering their 60s, the authors reexamined this association by measuring the relative risk of prostate cancer among a cohort of men who were stratified as either exposed or unexposed to Agent Orange between the years 1962 and 1971 and who were followed during the interval between 1998 and 2006. METHODS: All Vietnam War era veterans who receive their care in the Northern California Veteran Affairs Health System were stratified as either exposed (n=6214) or unexposed (n=6930) to Agent Orange. Strata-specific incidence rates of prostate cancer (International Classification of Diseases, 9th Revision code 185.0) were calculated. Differences in patient and disease characteristics (age, race, smoking history, family history, body mass index, finasteride exposure, prebiopsy prostate-specific antigen (PSA) level, clinical and pathologic stage, and Gleason score) were assessed with chi-square tests, t tests, a Cox proportional hazards model, and multivariate logistic regression. RESULTS: Twice as many exposed men were identified with prostate cancer (239 vs 124 unexposed men, respectively; odds ratio [OR], 2.19; 95% confidence interval [95% CI], 1.75-2.75). This increased risk also was observed in a Cox proportional hazards model from the time of exposure to diagnosis (hazards ratio [HR], 2.87; 95% CI, 2.31-3.57). The mean time from exposure to diagnosis was 407 months. Agent Orange-exposed men were diagnosed at a younger age (59.7 years; 95% CI, 58.9-60.5 years) compared with unexposed men (62.2 years; 95% CI, 60.8-63.6 years), had a 2-fold increase in the proportion of Gleason scores 8 through 10 (21.8%; 95% CI, 16.5%-27%) compared with unexposed men (10.5%; 95% CI, 5%-15.9%), and were more likely to have metastatic disease at presentation than men who were not exposed (13.4%; 95% CI, 9%-17.7%) than unexposed men (4%; 95% CI, 0.5%-7.5%). In univariate analysis, distribution by race, smoking history, body mass index, finasteride exposure, clinical stage, and mean prebiopsy PSA were not statistically different. In a multivariate logistic regression model, Agent Orange was the most important predictor not only of developing prostate cancer but also of high-grade and metastatic disease on presentation. CONCLUSIONS: Individuals who were exposed to Agent Orange had an increased incidence of prostate cancer; developed the disease at a younger age, and had a more aggressive variant than their unexposed counterparts. Consideration should be made to classify this group of individuals as 'high risk,' just like men of African-American heritage and men with a family history of prostate cancer.

BACKGROUND: Technologic advances in communications have facilitated the development and diffusion of telemedicine. Most applications have focused on remote outpatient management of medical conditions. We assessed the impact of introducing remote video conferencing during the immediate postoperative period (telerounds) on patient-reported satisfaction with their hospitalization. STUDY DESIGN: Between October 2002 and June 2003,85 patients undergoing elective laparoscopic or percutaneous urologic procedures were enrolled in a trial testing the impact of telerounds on patients' satisfaction with their hospitalization. Participants were entered into one of three postoperative care arms: standard once-daily attending bedside rounds; standard once-daily attending level bedside rounds plus one afternoon telerounding visit; or a substitution of one daily bedside round with a robotic telerounding visit. Participants completed a validated patient satisfaction survey 2 weeks after hospital discharge. RESULTS: Eighty-five individuals (100% response rate) completed the questionnaire. With responses dichotomized to "excellent" or "other," patients in the telerounding arm demonstrated statistically substantial improvements in ratings of examination thoroughness, quality of discussions about medical information, postoperative care coordination, and attending physician availability. Patients in the robotic telerounding arm indicated considerably higher satisfaction with regard to physician availability. After adjusting for age differences, ratings of each of the previously listed aspects of care remained notably improved in the telerounding arm. CONCLUSIONS: Telerounding either as an additional visit or as a substituted bedside visit is associated with increased patient satisfaction in postoperative care. This type of interaction appears to acceptably facilitate physician communication with hospitalized patients.